Acid Reflux Disease Complications
Hemorrhage and Perforation
Hemorrhage and esophageal perforation are rare complications of reflux esophagitis and are usually associated with deep esophageal ulcers or severe diffuse esophagitis. Clinically important hemorrhage has been reported in 7% to 18% of patients with GERD. Esophageal perforations are very rare in the PPI era, but they can result in mediastinitis and can be fatal if they are not rapidly recognized and treated.
Peptic Esophageal Strictures
Strictures occur in 7% to 23% of patients with untreated reflux esophagitis, especially in older men. They usually evolve over many years and may be linked to the long-term use of nonsteroidal antiinflammatory drugs. The mechanism of stricture formation is complex, starting as a reversible inflammatory process with edema, cellular infiltration, and vascular congestion, progressing to deposition of connective tissue and collagen, and ending in irreversible fibrosis. With the onset of dysphagia, there is often less heartburn, reflecting the stricture’s acting as a barrier to reflux. Dysphagia is usually limit to solids, but it may progress to liquids. Unlike malignant strictures, patients with peptic strictures have a good appetite, alter their diet, and lose little weight.
Radiographically, peptic strictures are smooth-walled, tapered, circumferential narrowings in the lower esophagus, which are usually less than 1 cm long, but occasionally they extend to 8 cm in length. In these unusual cases, the clinician should suspect a predisposing condition, such as the Zollinger-Ellison syndrome, superimposed pill esophagitis, or prolonged nasogastric intubation. A stricture in the middle to upper esophagus should raise the suspicion of Barrett esophagus or malignant disease. Although once controversial, most data today suggest that a Schatzki ring is a forme fruste of an early peptic stricture. In all cases, the nature of a peptic stricture needs to be confirmed by endoscopy with biopsies because some patients may have Barrett esophagus or unsuspected cancer.